=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457982951
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELSIE LINDAHL LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2020
-----------------------------------------------------
Last Update Date | 02/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3 9TH AVE W
-----------------------------------------------------
City | POLSON
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59860-5136
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-250-3112
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36995 BAPTISTE RD
-----------------------------------------------------
City | RONAN
-----------------------------------------------------
State | MT
-----------------------------------------------------
Zip | 59864-8653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 406-250-3112
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 15964
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | LMT-LMT-LIC-15964
-----------------------------------------------------
License Number State | MT
-----------------------------------------------------